Today’s Date: __________________

Summer Camp: ___/____/2018 - ____/____/2018;
Monday through Friday, from 8:00 am until 5:00 pm
New Camper______ Returning Camper______


1. Student Information

Name: ________________________________________

School: ______________________________ Grade: ___________

After School location:

Allergies/Food: ________________

Chronic Illness/Medication:_______________________________

Strengths/Needs: ______________________________________

Birth Date: _____________________

Names of siblings who will also attend Summer Camp: _____________________________                                                                                




Notes: ____________________________                                                                                  



2. Parent/Guardian Information

Name: ______________________________                                                               __

Address: ___________________________                                                                                                                                                                                                                              

Home Phone: _______________________

Work Phone: ________________________

Cell Phone: _______________________

Name: _________________________

Address: __________________________


Home Phone: _________________________

Work Phone: ___________________________

Cell Phone: ____________________________


TDY :__________________

3. Student Pick-up Information: Pick-up Only

Please list persons with phone numbers who you give permission to pick-up your child from the program.


Name:_____________________________ Phone:_____________________________

Name:______________________________ Phone:_____________________________

Name:______________________________ Phone:_______________________________

4. Emergency Contact Information 

In the event of an emergency, please list two people we may contact who know your child and can take full responsibility should you not be available.

Name: ______________________ Home Phone:_______________ Work Phone:________________

Name: ______________________ Home Phone:_______________ Work Phone:________________

5 T-Shirt Size

Youth Size: ___S ___M____L Adult Size: ____S ____M ____L ____ XL ___1X

6. Parent/Guardian Consent for Photographs and Internet Use

I give my consent to the Hands That Make A Difference (HTMAD) SCP to photograph my child and to use such pictures and/or stories in connection with any of their work without consideration of compensation of any kind, and I do release HTMAD from any claims whatsoever which may arise in said regards. Yes No

I give my consent to the Hands That Make A Difference (HTMAD) SCP to allow my child to use the internet under the supervision of the After School Program staff. Yes No

7. Parent/Guardian Consent to Participate in the After School Program

Youth are required to maintain a minimum monthly attendance rate of 90%. Youth are required to attend at least three program hours daily, unless a written early dismissal policy is in place. Failure to do so can cause lost of placement in program and slot being given to another applicant.

In case of an emergency injury or illness, I authorize the HTMAD to call the Emergency Medical Services (911). As legal guardian of the above listed student, a minor, I authorize the HTMAD representative designee to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and/or dentist.

The HTMAD SCP is not responsible for personal items. I have read and understand the above.

I give my consent for my child to attend the Summer Camp Program and participate in its activities. Yes No

Parent/Legal Guardian Signature__________________________________


Would you prefer to have formed emailed to you? Email request to info@handsthatmakeadifference.org

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